ABSTRACT
Gastric cancer is one of the leading causes of cancer-related mortality worldwide. Endoscopic submucosal dissection (ESD), when indicated based on tumor size, stage, and histological characteristics, is a highly successful curative, minimally invasive, non-surgical endoscopic treatment option. However, the risk of adverse events is higher compared to traditional methods. Here, we present a case of ESD in an early-stage gastric carcinoma and endoscopic closure using a new hand-suturing system.
INTRODUCTION
Gastric cancer is a leading cause of cancer-related mortality worldwide [1]. Early diagnosis and treatment interventions improve prognosis and mitigate adverse outcomes [2, 3]. Endoscopic submucosal dissection (ESD), when indicated based on tumor size, stage, and histological characteristics, is a highly successful curative, minimally invasive, non-surgical endoscopic treatment option [4]. However, the risk of adverse events, such as early or delayed perforation and bleeding, is higher with traditional methods like endoscopic mucosal resection and polypectomy [5]. Here, we present a case of ESD in an early-stage gastric carcinoma (EGC) and endoscopic closure using a new hand-suturing system.
CASE PRESENTATION
A 77-year-old male patient presented with gas, bloating, and nausea that had persisted for the past month, which were alleviated with medical treatment and diet. His medical history included ischemic heart disease, for which aspirin and clopidogrel were administered. Upper endoscopic examination revealed irregular areas with unclear borders in the greater curvature and posterior wall of the corpus-antrum junction, with widespread intestinal metaplasia throughout the stomach. Chromoendoscopy with indigo carmine after acetic acid washing revealed a flat, irregular area approximately 7 cm in diameter without ulcers (Figures 1, 2). Biopsies reveal intramucosal well-differentiated adenocarcinoma with high-grade dysplasia. Endoscopic ultrasound showed an intact muscularis propria and submucosal layer with no regional lymph nodes. Positron emission tomography did not show distant metastasis or lymph node involvement. Considering the patient’s comorbid conditions and written consent, ESD was performed under general anesthesia. A 155x105 mm en-bloc resection specimen was obtained. There was no muscular damage in the resection area (Figure 3). Prophylactic coagulation was applied to visible vascular areas. Due to the patient’s age and the necessity for anticoagulant and antiplatelet therapy, the resection area was closed using an endoscopic needle holder (Olympus, Sutuart, FG 260, Tokyo, Japan) with absorbable barbed suture (V-Loc 180, 3-0, Medtronic Ltd, Dublin, Ireland) (Figures 4, 5). Anticoagulant therapy was resumed 12 hours post-procedure per cardiology’s recommendation, and the patient was discharged on postoperative day 2. Histopathological examination confirmed intramucosal carcinoma with high-grade dysplasia, approximately 10 cm in diameter (Figure 6). The vertical and horizontal margins were negative. No lymphovascular involvement was observed. Six months later, endoscopic follow-up revealed a linear scar without residual or recurrent lesions or metachronous lesions.
DISCUSSION
In the treatment of EGC, ESD has been a highly successful curative, non-surgical treatment option not only in East Asia but also increasingly in Western countries [6]. However, compared with traditional methods, there is a higher risk of adverse events, such as early and late bleeding and perforation. These risks increase with factors such as age, sex, lesion size, resection area, location, comorbid conditions like cirrhosis and renal failure, and anticoagulant-antiplatelet therapy [7-9]. In this case, the resection area was successfully closed using a new suturing system. After the procedure, clopidogrel and aspirin were immediately resumed, and no early or late bleeding occurred during follow-up.
One issue following extensive resection is the development of strictures due to healing. The risk of strictures increases with the size of the resection area, presence of fibrosis, inflammation, neovascularization, and fibroblast activity [10-12]. Endoscopic suturing has been reported to result in less neovascularization and fibroblast activity [13]. In our case, despite the large resection area, no symptomatic or endoscopic strictures were observed during follow-up.
In patients with EGC and comorbidities requiring anticoagulant and antiplatelet therapy, ESD can be successfully performed regardless of lesion size at experienced centers. We believe that new endoscopic suturing systems will play a significant role in preventing late post-procedure adverse events.